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Joaquin County-Environmental Health Depot^ t[ 304 E Webei ..venue-Third Floor-Stockton CA 95202-Phone. 209468-3420 APPLICATION ENVIRONMENTAL IIEALTII PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Condlllonal Permit ❑ Multiple Years(Permanent(lousing Camps only) ❑Annual Permit for Calendar Year ❑Amended Permit: 'Change of Operator •Change or Owner *Change of Operator Address *Change of Owner Address •Addillonal Employees Permit ID#: 0010928 Please Note any Corrections or Changes in Facility/Operator Blfornmtinn directly on this Camp ID#: -1 q _ i� ( Site Now: TOSTA#1 HENRY Location: 20662 SAN JOSE RD.TRACY Operator: HENRY&LINDA TOSTA Mailing Address: 20662 SAN JOSE RD,TRACY CA 95304 Facility Phone#:(209)836-1286 Legal Owner: TOSTA,HENRY&LINDA(#1) New Owner f ❑Yes ❑ No Owner Address: 20662 SAN JOSE RD,TRACY CA 95304 Owner Phone#:(209)835-0687 Community Facilities Provided by Camp, Community Kitchen I ❑ Yes ❑ No s Men: NumberofToilets Number of Showers Number of Lavatories Women: Number of T'oilels Number of Showers Number of lavatories Romaine Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees Dormitories from I / I / Od' m I_Z/ ;// U rF Crop SF Dwellings / from t$t$�h-B=q--to_ll Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MI /RV Spaces Note TOTALS Y, Camps occupied by 25 or more Employees for 60 or more days In a year Igr Require a PUBLIC WATER SYSTEM Permit El Inactive Important: In order to protect your land use status,ifcamp will not be used this year but is intended for mein the future,Cheek this Box and return this application. ..y Fee Schedule YJ Permanent Camp Annual Permit Fe $35.00+ Number of Employees 5 @$12.00 each=$ -- "y" Orchard Camp Permit Fee $95.00=S Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee 520.00+ Number of Additional Employees @$12.00 each=S ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ . Fee must be submitted with Application TOTAL FEF,DUES � 1Q0, oD Remit TOTAL.FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CIIECKS PAYABLE to EDD Applicant agrees to all necessary Inspection,Incident to issuance of a PERMIT 10 OPFAtATE. Applicant agrees that this project(camp)shall he operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACI',Chapter I, Poll I, Division 13 or the California Health and Safety Code and Chapter I, ubcliapter 3,Title 25,California Cofte of Regulations. Applicant Name "Title �jyc�es, ❑ Partnership (Please PRINT or TYPE) 777 ' ❑Corporation Address ♦ Phone 7_D�- i23<a-fLd��o Applicant Signature Date of Application Amount Paid Data of Payment Payment Type Chec R elpt# Received By Account ID [q O G D 1000 L( 1._� IrL 9 q � 0011126 Facility ID Program Record ID PIE 1 Assigned to PWS ID FA0007393 -PA0506996- 204? ;1.-7 7} 0018-TRINDADE N/A SzYta'7 b Regon Is 7008.rg1 _DD u 101t. o A'r k 1 11 V Application Printed:4/7/2004